Ethical issues in living organ donation: donor autonomy and beyond.

Despite nearly 50 years of experience with living kidney donation, ethical questions about this practice continue to haunt us today. In this editorial I will address two of them: (1) Given the possibility of limited understanding and coercion, how can we be sure that a person who offers to donate an organ is acting autonomously? and (2) Do people have a right to donate? The universal requirement for informed consent is the traditional method for ensuring that a person is acting autonomously. But, while obtaining fully informed consent is desirable, it may not always be achievable or necessary. When the recipient is very dear to the potential donor, the donor may base his decision primarily on care and concern rather than on a careful weighing of risks and benefits. I will argue that consent that emanates from such deep affection should be considered just as valid as consent that is fully informed. But consent is not enough. There is no absolute right to donate an organ. If there were such a right, then some physician would be obligated to remove an offered organ upon request, regardless of the risks involved. I do not believe that physicians have such an obligation. Physicians are moral agents who are responsible for their actions and for the welfare of their patients. Therefore, while the values and goals of the potential donor should be given great weight during the decision-making process, physicians may justifiably refuse to participate in living organ donation when they believe that the risks for the donor outweigh the benefits.

Public attitudes toward kidney donation by friends and altruistic strangers in the United States.

BACKGROUND: A severe shortage of organs is one of the major barriers facing transplantation today. One promising approach to this serious problem is to increase the use of genetically unrelated living kidney donors. Because of excellent results and favorable ethical considerations, spousal donation has become a widely accepted practice in the United States. The majority of U.S. transplant centers are now also willing to consider friends as donors, but they seem to be less comfortable about this donor source and most centers are opposed to using strangers. This study was designed to see what the public thinks about these issues. METHODS: A telephone survey of 1009 randomly selected adults living in the U.S. was conducted by the Gallup Organization. The survey asked about the acceptability of kidney donation by close friends and altruistic strangers and the willingness of respondents to make such donations themselves. RESULTS: Over 90% of respondents believe that kidney donation by close friends is acceptable and 80% feel the same way about kidney donation by altruistic strangers. Most respondents (76%) would probably donate a kidney to a close friend with renal failure and 24% said they would even donate a kidney to a stranger for free. CONCLUSION: It seems that the vast majority of American adults believe that living kidney donation by friends and altruistic strangers is an acceptable practice and many would consider making such donations themselves. When considered along with excellent results and favorable ethical arguments, these data suggest that kidney donation by friends and altruistic strangers should be considered as acceptable as is donation by spouses.

Evolution of attitudes at U.S. transplant centers toward kidney donation by friends and altruistic strangers.

A severe shortage of organs is one of the major barriers facing transplantation today. One of the proposals designed to overcome this serious problem is to increase the use of genetically unrelated living kidney donors. Excellent results have been achieved with these volunteers and cogent arguments have been made that this practice is ethically acceptable. These considerations have encouraged many transplant centers to break with tradition and accept spousal donors. To see if there has been a similar change in attitudes toward other types of unrelated living donors, a survey was mailed to 208 U.S. renal transplant centers; 129 (62%) were returned. Ninety-three percent of responding centers said they would accept a close friend as a kidney donor. Although the majority of centers would not consider an altruistic stranger, a sizeable minority (38%) would. When compared with the results of previous surveys, these data show that attitudes toward unrelated living kidney donors have gradually become much more liberal.

Consensus statement on the live organ donor.

OBJECTIVE: To recommend practice guidelines for transplant physicians, primary care providers, health care planners, and all those who are concerned about the well-being of the live organ donor. PARTICIPANTS: An executive group representing the National Kidney Foundation, and the American Societies of Transplantation, Transplant Surgeons, and Nephrology formed a steering committee of 12 members to evaluate current practices of living donor transplantation of the kidney, pancreas, liver, intestine, and lung. The steering committee subsequently assembled more than 100 representatives of the transplant community (physicians, nurses, ethicists, psychologists, lawyers, scientists, social workers, transplant recipients, and living donors) at a national conference held June 1-2, 2000, in Kansas City, Mo. CONSENSUS PROCESS: Attendees participated in 7 assigned work groups. Three were organ specific (lung, liver, and kidney) and 4 were focused on social and ethical concerns (informed consent, donor source, psychosocial issues, and live organ donor registry). Work groups' deliberations were structured by a series of questions developed by the steering committee. Each work group presented its deliberations to an open plenary session of all attendees. This information was stored and shaped into a statement circulated electronically to all attendees for their comments, and finally approved by the steering committee for publication. The term consensus is not meant to convey universal agreement of the participants. The statement identifies issues of controversy; however, the wording of the entire statement is a consensus by approval of all attendees. CONCLUSION: The person who gives consent to be a live organ donor should be competent, willing to donate, free from coercion, medically and psychosocially suitable, fully informed of the risks and benefits as a donor, and fully informed of the risks, benefits, and alternative treatment available to the recipient. The benefits to both donor and recipient must outweigh the risks associated with the donation and transplantation of the living donor organ.

Diuretic-induced hyponatremia.

Diuretics are one of the most common causes of severe hyponatremia. Yet, despite several relevant studies and years of clinical experience, the mechanism and optimal treatment of diuretic-induced hyponatremia remain unclear. What is clear is that most cases are caused by thiazide rather than loop diuretics and that severe hyponatremia can develop very rapidly in susceptible patients. In this review, I will discuss the pathogenesis, clinical features, prevention, and treatment of diuretic-induced hyponatremia in the hope that increased awareness and understanding will reduce the incidence and complications of this potentially life-threatening syndrome.

Should all human immunodeficiency virus-infected patients with end-stage renal disease be excluded from transplantation? The views of U.S. transplant centers.

BACKGROUND: Human immunodeficiency virus (HIV)-infected patients have generally been excluded from transplantation. Recent advances in the management and prognosis of these patients suggest that this policy should be reevaluated. METHODS: To explore the current views of U.S. transplant centers toward transplanting asymptomatic HIV-infected patients with end-stage renal disease, a written survey was mailed to the directors of transplantation at all 248 renal transplant centers in the United States. RESULTS: All 148 responding centers said they require HIV testing of prospective kidney recipients, and 84% of these centers would not transplant an individual who refuses HIV testing. The vast majority of responding centers would not transplant a kidney from a cadaveric (88%) or a living donor (91%) into an asymptomatic HIV-infected patient who is otherwise a good candidate for transplantation. Among the few centers that would consider transplanting an HIV-infected patient, not a single center had performed such a transplant in the year prior to the survey. Most centers fear that transplantation in the face of HIV infection would be harmful to the individual, and some believe that it would be a waste of precious organs. CONCLUSIONS: The great majority of U.S. renal transplant centers will not transplant kidneys to HIV-infected patients with end-stage renal disease, even if their infection is asymptomatic. However, advances in the management of HIV infection and a review of relevant ethical issues suggest that this approach should be reconsidered.

Should children ever donate kidneys? Views of U.S. transplant centers.

BACKGROUND: Living donors provide the best outcome for children undergoing renal transplantation. Most of these donors are parents. When parents are unable to donate, siblings are often considered. But what if the siblings are also children? Should they be permitted to donate? METHODS: To see how this difficult ethical question is currently handled, a survey was mailed to all U.S. renal transplant centers asking for their policies regarding kidney donation by minors (< 18 years old). RESULTS: Among the 117 responding centers that offer pediatric transplantation, the vast majority (81%) prefer living related donors for pediatric recipients. Yet, only 33% of responding centers would allow a monozygotic twin minor to donate a kidney to his or her twin, and even fewer (21%) would allow a nontwin minor to donate to a sibling. In the year before the survey, only two of these centers had actually used a child as a kidney donor. Furthermore, the great majority of responding centers (68%) require living donors to be at least 18 years old. CONCLUSIONS: These data indicate that most U.S. transplant centers are opposed to using children as living kidney donors. On the other hand, a careful analysis of this issue suggests that although donation by a minor should be uncommon, a complete ban of this practice may be unwarranted. In unusual circumstances in which no other suitable donor is available, consenting mature minors, and even rare immature minors who are highly likely to benefit from donating, may be ethically acceptable. Although there are probably no absolute wrong or right answers, the question of kidney donation by children should be readdressed.